RFC Evidence Checklist worksheet
Use this checklist to organize sitting, standing, walking, lifting, concentration, attendance, and pace limits.
| Item | Your notes |
|---|---|
| Use This Checklist To Organize Sitting | ____________________________ |
| Standing | ____________________________ |
| Walking | ____________________________ |
| Lifting | ____________________________ |
| Concentration | ____________________________ |
| Attendance | ____________________________ |
| Pace Limits | ____________________________ |
| Provider | ____________________________ |
| Dates of treatment | ____________________________ |
| Diagnosis or condition | ____________________________ |
| Key test or finding | ____________________________ |
| Treatment tried | ____________________________ |
Before you use this checklist
- Copy dates and instructions from the current SSA notice rather than memory.
- Keep originals and work from copies.
- Do not send Social Security numbers, bank information, or full medical files to an unverified recipient.
- Save filing confirmations and proof of any time-sensitive submission.